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Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. Six patients (ages 28–60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Phalloplasty may be performed in patients with acquired or congenital penile insufficiency or transgender individuals who desire phallic construction. Demand for neophallus creation and prosthesis placement has increased in recent years with growing coverage for gender affirming surgery among transgender patients. This report describes consideration of prosthetic implantation in neophallic reconstruction. Prosthesis implantation in a neophallus requires special consideration regarding avoidance of critical structures, proximal prosthesis anchoring, and distal cushioning in patients without native corpora cavernosa. Neophallus prostheses are associated with increased risk of infection, extrusion, erosion, and device migration relative to standard prostheses, with a high revision rate. Implanters should have a thorough understanding of neophallic reconstructive technique prior to proceeding with device placement. Current literature on this subject consists predominantly of retrospective reviews and case reports with variable outcome measures. The creation of validated assessment tools will provide more meaningful data to inform provider counseling and patient expectations.

To examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP).This was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1 %) open RP (ORP) and 26,465 (27.9 %) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination.Following RP, 35,591 (52.2 %) received mechanical, 4,945 (7.2 %) pharmacologic, 7,720 (10.6 %) combination, and 20,438 (30.0 %) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25 % of all procedures. Men with2 comorbidities (OR = 2.44; 95 % CI 1.78-3.35) and those who were black (OR = 1.44; 95 % CI 1.06-1.97) were more likely to have a VTE. Men who had RALP (OR = 0.61; 95 % CI 0.45-0.99), surgery at high-volume hospitals (OR = 0.45; 95 % CI 0.28-0.73), or received prophylaxis (OR = 0.67; 95 % CI 0.50-0.88) were less likely to develop a VTE.Despite the observation that VTE prophylaxis reduces the risk of VTE by 40 %, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.